Provider Demographics
NPI:1730581745
Name:KELLY, CRYSTAL (BA)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MISS
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:THOMASSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:921 SHARON CT
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9467
Mailing Address - Country:US
Mailing Address - Phone:850-830-7547
Mailing Address - Fax:
Practice Address - Street 1:921 SHARON CT
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9467
Practice Address - Country:US
Practice Address - Phone:850-830-7547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker